Paved with Good Intentions: A policy analysis on the disproportionate incarceration of people with mental illness in Washington State Sara Marquis A thesis submitted in partial fulfillment of requirements for the degree of Master of Public Health University of Washington 2017 Committee: Michael Stanfill Aaron Katz Program authorized to offer degree: Public Health © Copyright 2017 Sara Marquis 1 University of Washington Abstract Paved with Good Intentions: A policy analysis on the disproportionate incarceration of people with mental illness in Washington State Sara Marquis Chair of the Supervisory Committee: Michael Stanfill, Clinical Assistant Professor Department of Health Services Washington State is currently experiencing an unprecedented surge in incarceration among individuals with mental illness. This policy analysis aims to characterize the structural, judicial, legislative and policy decisions have led to this issue in Washington State, determine the barriers and facilitators of the problem, assess the efficacy of various interventions and develop recommendations for policy makers hoping to ameliorate the issue moving forward. Using historical and literature review, a mini-systematic review of mental health courts effect on jail recidivism and key informant interviews of stakeholders working with this population, the analysis outlines the scope and context of incarceration of people with mental illness and explores the feasibility potential interventions aimed at preventing arrest or mitigating poor outcomes after arrest. 2 Acknowledgement I would like to acknowledge the individuals who provided their time and insight to help inform this project. Kimberly Mosolf Attorney Disability Rights Washington: AVID Jail Project Callista Welbaum Program Manager King County District Regional Mental Health Court Richelle Nordeen Director of Forensic Services Sound Mental Health Daniel Nelson Crisis Intervention Team Coordinator Seattle Police Department Jesse Benet Diversion and Reentry Coordinator King County Behavioral Health and Recovery Division Sarah Safranek Librarian UW Health Sciences Library 3 Table of Contents Introduction 4 Historical Context 5 Institutionalization 5 Deinstitutionalization 7 Transinstitutionalization 12 Criminalization of mental illness 15 Today 17 Scope and Character 19 Types of crime 19 Intersectionality and vulnerable populations 20 Consequences 21 Consequences for people with mental illness 21 Consequences for society 22 Conceptual Framework 23 Sequential Intercept Model 23 Stakeholders 28 Key informant interviews 28 Interview methods 29 Community mental health 29 Police departments 30 Mental health courts 31 Local health and social services departments 32 Advocacy organizations 33 Themes 34 Lack of affordable housing 34 Limited community mental health 35 Crisis services 35 Low participation in mental health court 36 Lack of coordination between agencies 37 Lack of inpatient psychiatric beds 37 Assault in the third degree 37 Workforce issues 38 “Pockets of Innovation” 38 Analysis of Potential Approaches 38 4 Table of Evidence on Interventions 40 Housing Support 41 Crisis Intervention Teams and Other Crisis Solutions 44 Mental Health Courts 48 Conclusions 51 References 53 Appendices 63 Appendix 1: Abbreviations 63 Appendix 2: Timeline 64 Appendix 3: Key Informant Interview Questions 66 Appendix 4: Mini - Systematic Review of Mental Health Courts 67 5 Introduction Prisons and jails have become America’s de facto psychiatric hospitals. The statistics are ​ ​ sobering. In 2005, the US Department of Justice published a report noting that more than half of 1 all prison and jail inmates have a mental health problem. ​ There are now more than three times ​ as many people with serious mental illness in jails and prisons than in psychiatric hospitals nationwide.2 ​ Washington State is not immune from these national trends. Many consider state’s mental health system severely inadequate, with one of the lowest per-capita numbers of inpatient 3 psychiatric beds and one of the highest prevalence rates of mental illness in the nation. ​ The ​ limitations in our community mental health system and trends in incarceration have led to a shift in the locus of care for people with mental illness. A recent study among Medicaid recipients booked into jails in Washington showed 58% had a mental health diagnosis and over 78% had 4 active behavioral health needs. ​ Other studies show that 27.5% of patients discharged from ​ state psychiatric hospitals in Washington face arrest within 2 years of leaving the hospital.5 ​ This analysis explores the problem of incarceration among people with mental illness in Washington State. In this analysis, we will first outline the history of mental health care in Washington State and how various social, legal and political factors coalesced into the disproportionate incarceration of people with mental illness today. Next, we will characterize the scope and consequences of the issue based on literature review. We will then present a framework for conceptualizing this issue and describe key stakeholders working with those at risk of incarceration. Lastly, informed by literature review and key informant interviews, we will analyze various solutions to the factors that have led to disproportionate incarceration of 6 individuals with mental illness and propose recommendations for mitigating the issue moving forward. Historical Context Mental health care in Washington State has been subject to overarching national trends that led to the disproportionate incarceration of those with mental illness today. In studying the treatment of people with mental illness in Washington State and beyond, we see how various factors led to an era of deinstitutionalization and how the vacuum left by deinstitutionalization resulted in transinstitutionalization and ultimately, criminalization of mental illness. This historical analysis will explore the complex web of cultural zeitgeist, court rulings and policy changes that impacted our current state (see Appendix 2 for an overarching timeline). By looking to our past, we can hopefully mitigate or even avoid the pitfalls that have paved the way to the current situation and inform the development of solutions to our current system. Institutionalization Initially touted as a progressive alternative to life on the streets or criminal punishment, institutionalization in psychiatric hospitals promised more humane care of people with mental 6 illness when they initially appeared in the United States shortly before the civil war. ​ Prior to this ​ time, mental illness was often viewed as a moral failure on the part of the affected individual and 6 many people with mental illness were left to “wander the countryside.” ​ The first psychiatric ​ hospital in the territory that would later become Washington State was the “Insane Asylum of Washington Territory.” The hospital initially only housed 21 patients when it opened in Fort Steilacoom 1871. The name was later changed to “Western State Hospital” when Washington reached statehood in 1889.7 ​ 7 Over the subsequent decade, Western State Hospital’s patient census ballooned to over 200 patients, necessitating the creation of Eastern State Hospital in Medical Lake in 1891.8 ​ Overcrowding in both hospitals continued to escalate and eventually spurred public outcry, 9 which led to the opening of Northern State Hospital in 1912. ​ The bar for civil commitment ​ during this era was especially low, generally only requiring referral to treatment by someone 6 other than the patient -- often a family member. ​ Individuals institutionalized during this time ​ often stayed in state hospitals indefinitely with no clear pathway towards discharge. National trends during this time show a stark picture - the average length of stay in a state psychiatric 6 hospital by 1950 was 20 years. ​ This contributed to steep increases in state psychiatric hospital ​ populations. The population of people admitted to psychiatric hospitals grew significantly during this period as an increasing number of individuals were hospitalized indefinitely in state hospitals, usually on an involuntary basis and occasionally for political or personal reasons 6 unrelated to mental illness. ​ By 1955, we see the peak of the number of people institutionalized ​ 10,11 in Washington State, with over 7,500 housed in state psychiatric hospitals. ​ The nation was ​ experiencing a similar peak in the overall psychiatric hospital population at the time, with over a half million individuals institutionalized in the US that year.12 ​ During this period, people with mental illness faced very limited treatment options and admission to a psychiatric hospital was often the only option available for most people with severe mental illness. Treatments that did exist were largely ineffective and occasionally highly debilitating. With the advent of frontal lobotomy and the popularization of unmodified electroconvulsive therapy and insulin/cardiazol shock therapies, the 1940s and early 1950s saw 6 a particularly severe era of experimentation in psychiatry. ​ Beyond these limited and typically ​ 8 ineffective treatments, state psychiatric hospitals could offer little to patients beyond custodial care and most patients saw little relief from their psychiatric symptoms. Deinstitutionalization By the mid-1950s, public support for state psychiatric hospitals began to wane as the costs to taxpayers increased alongside hospital censuses. Stories of deteriorating conditions due to understaffing